CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2015 - 6/30/2017

Printed
Name:

Organization

?ab [kW/m

Check all covered companies and note average hours spent



Founda?on

(ULF) . .

UofL Housing 1

(ULH)

University
Holdings, Inc.
(U HI)

The Nucleus 

Real
Properties,
Inc. 

UofL Real

Estate
Foundation,
Inc. (U LREF)

Pediatric 

Medical
Office
Building, lnc.
(PMOB)

Louisville
Medical
Center
Development
Corporation


Other
Entityts):

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Ave rage
hours per

_week:

we?,




ULF-OO7279

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR - 5/30/2017

Printed

Name: PM). 

When used below, the term ?affiliated persons" include the following: your spouse,
domestic partner, child, mother, father, brother or sister; (ii) any corporation or
organization ofwhich you area board member, an officer, a partner, participate in
management or are employed by, or are directly or indirectly, a debt holder or the
beneficial owner of any class of equity secorities; and any trust or other estate in
which you have a substantial beneficial interest or as to which you serve as a trustee or
in a similar capacity.

When used below, the term ?business transactions" include, but are not limited to,
contracts of sale, lease, license and performance of services, whether initiated during 3
Covered Company's tax year or ongoing from a prior year. Business transactions also
include joint ventures in which either the profits or capital interest of the organization
and of the interested person exceeds 10%.

Business Transactions with Organization

1} Do you or an affiliated person conduct business with an organization?

if "Yes," describe your business transaction(s) with the organization and, specify which
one if you checked multiple organization(s) above:

2) Do you or an affiliated person own 35% of an entity (C-corporation, S-corporation,
Partnership, LLC or other entity type), directly or indirectly, that conducts business with
an organization?

if "Yes," describe your business transaction(s) with the organization and, specify which
one if you checked multiple organization(s) above:

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ULF-OO7280

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2016 - 6/30/2017

Printed

Name: @441affiliated person, in combination with other affiliated person(5}" own
35% of an entity {C?corporation, S?corporation, Partnership, LLC or other entity type),
directly or indirectly, that conducts business with an organization?

if ?Yes," describe your business transaction(s) with the organization and, specify which
one if you checked multiple organization{s) above:

4) Do you or an affiliated person, serve as an officer, director, trustee, or key employee
of an entity that does business with an organization?

If "Yes," describe your business transaction(s) with the organization and, specify which
one if you checked multiple organization(s) above:

5) Do you or an affiliated person serve as a partner, member, or shareholder of an entity
(with ownership interest in excess of 5% of a partnership or professional corporation)
that conducts business with an organization?

If describe your business transaction(s) with the organization and, specify which
one if you checked multiple organization(s) above:

6) Did you or an affiliated person receive a compensation payment in excess of $10,000
from an organization?

if "Yes," explain and, specify which one if you checked multiple organizations above:

Page ULF-OO7281

CONFLICT OF INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2016 - 6/ 30/ 2017

Printed ?3 
Name: 

7) Did you or an person receive grants or other assistance, including provision
of goods, services, or use of facilities from an organization? Grants include scholarships,
fellowships, internships, prizes, and awards.

If "Yes," explain and, specify which one if you checked multiple organizations above:

8) Do you have 35% control in an entity that received grants or other assistance,
including provision of goods, services, or use of facilities from an organization?

if "Yes," explain and, specify which one if you checked multiple organizations above:

9) Do you have any loans to or from an organization?

If "Yes," explain and, specify which one if you checked multiple organizations above:

10) Are you aware of any excess benefit transactions to report? An excess benefit
transaction is where an organization is directly or indirectly provided an economic benefit
Where the value of the benefit exceeds the value of the consideration received by the
organization.

If "Yes," explain and, specify which one if you checked multiple organizations above:

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NO

 

ULF-OO7282

CONFLICT or INTEREST QUESTIONNAIRE
FISCAL YEAR 7/1/2015 - 6/30/2017

Printed

Name: 9914, ($412424 

11] Are you or any affiliated persons a party to, or have an interest in, any pending legal
proceeding involving an organization?

If Yes," explain, and if an affiliated person is invoived, the identity of that affiliated person
and your relationship with that person:

12) Are you aware of any other events, transactions, arrangements or other situations that
have occurred or may occur in the future that you believe should be examined by an
organization's governing body?

If "Yes," explain and, specify which one if you checked multiple organizations above:

Signature: - 

Date: fl/d?/M f7

 

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ULF-OO7283